Detecting Alcohol-Related Problems in Trauma Center Patients.

Injury and alcohol are strongly associated. Trauma center clinicians have a unique opportunity to prevent future injuries by identifying patients with alcohol-related problems.

A lcoholrelated impairment has REASONS FOR SCREENING tient's alcohol use pattern is a been linked to an array of routine part of medical care (p. 3). serious and fatal injuries result Two trauma center studies highlight the ing from various mechanisms need to identify and treat trauma patients of injury, including traffic crashes, falls, who suffer from alcoholism. A Detroit

EFFECT OF ALCOHOL ON
domestic violence, suicide, and assault. study (Sims et al. 1989) of victims of

RECOVERY FROM TRAUMA
Most victims of trauma are treated in a violence noted that those patients with hospital emergency department (ED) and evidence of alcohol abuse were almost Excessive use of alcohol can cause several released. More seriously injured victims, twice as likely (48 percent vs. 28 percent) bodily changes that might increase illness however, may be treated at 1 of the more to sustain a second injury within 5 years and death rates among trauma patients than 400 trauma centers nationwide. Here, that required either ED treatment or re (Soderstrom 1989; Albin 1987; Gentilello clinicians not only treat physical injuries admission to a trauma center than were et al. 1993). Alcohol abuse could exacerbate but also have the opportunity to detect patients without evidence of alcohol abuse. conditions such as brain, spinal cord, and alcoholrelated problems 1 that might A Seattle study (Rivara et al. 1993a), heart injuries; shock resulting from blood otherwise go unrecognized.
with an average followup time of more than loss; impaired clotting of the blood; and As demonstrated by Gentilello and 2 years, assessed the relative risks of trau infectious diseases that may follow trauma. colleagues (1988), alcoholic trauma pa ma patients sustaining a second traumatic Large studies of trauma patients in tients are amenable to entering treatment episode requiring readmission. Among which outcome was assessed relative to programs; however, current practices in those who were intoxicated at the time living or dying have suggested that alco trauma centers do not facilitate that proc of the first admission, those judged possi hol use immediately prior to trauma either ess. Fewer than 25 percent of trauma bly alcoholic based on a screening inter has no effect on survival (Soderstrom and centers routinely test for alcohol and other view, and those who had elevated gamma Eastham 1987) or appears to be associated drugs of abuse, obtain patients' histories glutamyl transferase (GGT) levels (see with increased chances of survival (Ward of alcohol abuse, and employ fulltime below), the relative risks of readmission et al. 1982). As stated by Waller (1988), drug dependence counselors (Soderstrom for injury compared with the risks among and Cowley 1987).
subjects without those characteristics were the methodologies that were used to This article discusses the need for 2.5, 2.2, and 3.5 times higher, respectively. assess alcohol's effect on mortality in alcohol use assessment as a routine part Commenting in part on the problem of studies such as those cited above may be of trauma center care and evaluates some alcoholrelated repeat trauma episodes, screening tests for usefulness for this Gordis (1991)  flawed because nothing is known about kinetic or other energy forces causing injuries, and analysis may be limited only to inpatients, with no knowledge about those not in jured, those with injuries not requir ing treatment, those seen only in the emergency department, or those who died at the scene (p. 1632).
In a North Carolina study of more than 1 million vehicular crash victims, Waller and colleagues (1986) found that when age, gender, vehicle weight, and deforma tion incurred in the crash, and other factors were considered, the intoxicated driver was more likely to die or suffer serious injury. In a Maryland study, Dischinger and col leagues (1988) noted that vehicular crash victims who were intoxicated were more likely to die at the scene of injury than were nonintoxicated crash victims.
A recent Seattle study (Jurkovich et al. 1993) obviated many of the previous trauma center study concerns expressed by Waller (1988). Results indicated that acute intoxication had no effect on the death of trauma patients relative to place of death, that is, either at the scene or within or after 24 hours after admission to the trauma center. The study did demonstrate a higher risk of complications, particularly infec tions, among patients with evidence of chronic alcohol abuse compared with other patients. In another Seattle trauma center study, Gentilello and colleagues (1993) demonstrated an association be tween the occurrence of infections in patients who had penetrating wounds and a blood alcohol concentration (BAC) of at least 0.2 percent at the time of admission. An additional Seattle study (Gurney et al. 1992) suggested that intoxicated patients with brain injuries are at greater risk of developing pneumonia and respiratory distress than are nonintoxicated patients.
Overall, there is a dearth of outcome studies of the type mentioned above. Al cohol affects multiple organs and organ systems, and its effects will vary accord ing to age of onset of alcohol use, years of use, drinking patterns, gender, preexisting diseases, and a host of other factors.

PATIENT PROFILE
Each year, approximately 800 to 1,000 people per million sustain injuries requir ing treatment in a trauma center (National Highway Traffic Safety Administration 1987). Demographic information for 16,251 patients treated at the R Adams Cowley (RAC) Shock Trauma Center in Baltimore, MD, during a 6year period from July 1987 to June 1993 is presented in table 1. This freestanding trauma center is the core facility of Maryland's comprehensive system of emergency trauma care. The gender, age, and mecha nism of injury profiles of the center's patients reflect those of patients treated in trauma centers throughout the United States (Champion et al. 1990).
BAC is determined for more than 90 percent of patients admitted to the RAC Shock Trauma Center from the scene of injury. As shown in table 1, alcohol use immediately prior to injury is highest among men, patients 21 to 49 years of age, motorcyclists, struck pedestrians, and victims of intentional violence. The rates of preinjury alcohol use reported in table 1 are similar to those found at other centers for victims of both intentional and uninten tional injury (Rivara et al. 1993b;Sloan et al. 1989;Lindenbaum et al. 1989). Alcohol is the drug most frequently detected in trauma patients; however, a spectrum of other drugs is found also, either alone or in combination with alcohol (Sloan et al. 1989;Lindenbaum et al. 1989;Soderstrom et al. 1988).

ASSESSING ALCOHOLISM IN TRAUMA CENTER PATIENTS
Almost a decade ago, Reyna and col leagues (1985) stated, "An [ED] visit for loss of consciousness, abdominal trauma, or even seemingly insignificant lacerations and fractures may be the first and only opportunity the surgeon has to identify undercover alcoholics" (p. 197). Taking advantage of that opportunity may be difficult, because the ED is geared for immediate treatment of patients' injuries, after which most patients are sent directly home. Also, patients with elevated BAC's are usually in no condition to benefit from counseling services prior to leaving the ED.
On the other hand, admission to a trauma center allows identification, coun seling, and referral for treatment of an addiction problem. However, a national survey, documenting responses from 316 trauma centers, revealed that although resources to perform BAC testing were available at all but 2 of those centers (99.4 percent), BAC testing was a standard clini cal practice at only onethird (38.3 percent) (Soderstrom et al. 1994). The predominant reason given for not obtaining BAC's is that the test is regarded as "clinically not important." These results did not vary sig nificantly from a survey conducted 5 years earlier (Soderstrom and Cowley 1987). In addition, fewer than 40 percent of the re sponding centers did not test routinely for other drugs (Soderstrom et al. 1994).
The "clinically not important" response of trauma center clinicians regarding alco hol testing probably reflects a general dis interest in alcoholism and other chemical dependence problems. A study of Johns Hopkins medical students and residents by Geller and colleagues (1989) suggests that those who were "further along" in their education were more likely to regard alco holism as a "character weakness" and to believe that treatment/rehabilitation "does not work" (pp. 3117-3118).
Similarly, Chang and colleagues (1992) found in a survey of more than 1,000 emer gency medicine specialists that most con sidered alcoholics "difficult to treat." These specialists did agree that alcoholism is a "treatable disease" but indicated that nei ther physicians (excluding psychiatrists) nor surgeons are effective clinicians for the treatment of alcoholism. These attitudes are not surprising: because the treatment of lifethreatening conditions must take prece dence in ED's and trauma centers, the iden tification and treatment of alcoholism is deemed a secondary concern.

INDICATORS OF ALCOHOLISM IN TRAUMA CENTER PATIENTS
Several indicators can be used to help clinicians screen for alcohol problems among patients in trauma centers. Potential indicators include intoxication on admis sion, presence of cirrhosis, levels of liver enzymes and other biological markers, results of interview questionnaires, and a history of other drug use. No single test is sufficient for screening this population. Information from demographic data must be linked to physiologic data, BAC and other toxicology results, and interview results to identify those trauma patients who require a formal evaluation by addiction clinicians.

Intoxication
Many injured drivers admitted to trauma centers are intoxicated at the time of admission (Rivara et al. 1993b;Soder strom et al. 1988;Stoduto et al. 1993). Intoxication should be considered a strong indicator of possible alcoholism. For example, psychiatric evaluations of drivers convicted of alcoholimpaired driving indicated that about onethird had a diagnosis of alcohol dependence and about onehalf could be characterized as having an alcohol abuse disorder (Kruzich et al. 1986;Miller et al. 1986).

Cirrhosis
The result of a prolonged history of heavy alcohol consumption, cirrhosis can be de tected through laboratory testing of liver function. However, biochemical evidence of liver dysfunction is not detected as fre quently as expected among trauma victims, probably because this population tends to be younger than the classic alcoholic with liver disease. (The average patient with alcoholic cirrhosis has been drinking heavi ly for 10 to 20 years [Grant et al. 1988].) In a study of preexisting disease among 27,029 trauma patients discharged alive from California hospitals, a discharge diagnosis of cirrhosis was recorded for only 0.5 percent. The highest rates were in the 45 to 54year and the 55 to 64year age groups, being 1.1 percent and 1.5 percent, respectively (MacKenzie et al. 1989).
In a review of trauma registry data from two Pennsylvania trauma centers involving more than 27,000 patients over a 9year period, Tinkoff and colleagues (1990) found only 40 (1.4 percent) patients with cirrhosis. The mean age of the patients in that diagnostic group was 58 years. In another trauma registry review of almost 8,000 patients admitted to the RAC Shock Trauma Center, mentions of cirrhosis were noted less than 1 percent of the time (Milzman et al. 1992). These studies sug gest that cirrhosis is rarely encountered in trauma centers. Hence, a search for that condition will provide a low yield for iden tifying trauma patients with alcoholism.

Biological Markers
In a recent study, Rivara and colleagues (1993b) assessed levels of GGT and gluta mate dehydrogenase (GDH) among both intoxicated (BAC at least 0.1 percent) and nonintoxicated patients admitted to Seattle's Harborview Medical Center. GGT and GDH are liver enzymes whose levels in the blood are used as markers of liver disease (for more information on biological mark ers, see the article by Salaspuro,. Overall, 47.0 percent of the 2,657 patients had an elevated BAC, of whom 76 percent were intoxicated. Sixty percent of the intoxicated patients were younger than 35 years of age. Among the nonintoxicated patients, 11.4 percent had elevated GGT levels and 27.6 percent had elevated GDH levels, compared respectively with 28.0 percent and 35.6 percent of the intoxicated patients. In both intoxicated and nonintoxi cated patients, the highest percentages of abnormal enzyme elevations were found in age groups above 45 years. In a study assessing the value of liver function tests to predict injury to the liver and other abdominal organs, Sahdev and colleagues (1991) measured the liver en zymes glutamic oxaloacetic transaminase (SGOT) and glutamic pyruvic transaminase (SGPT) in the serum (liquid part of the blood) of 309 patients. Levels of these enzymes were normal in 80.9 percent of the patients. However, the researchers found a significant association between elevated SGOT or SGPT levels and alcohol levels.
Test results for currently available markers do not yield a high rate of speci ficity 2 in the diagnosis of alcoholism. For example, in one Seattle study (Rivara et al. 1993b), only 30.4 percent of the intoxicated patients with results suggestive of alcohol ism, based on a frequently used test, had elevated GGT levels. GDH also appeared to be a poor marker for alcoholism in trauma patients. Measurement of an abnor mal blood protein called carbohydrate deficient transferrin (CDT) may prove to be a more accurate method of detecting recent alcohol abuse (Stibler 1991). The CDT marker test, which has not been approved for diagnostic clinical use, has yet to be studied in a population of trauma patients.

Patient Interviews
In studies at the RAC Shock Trauma Center (Soderstrom et al. 1992) and Seattle's Harborview Medical Center (Rivara et al. 1993b), BAC test results of intoxicated and nonintoxicated patients were compared with interview results. In both studies, interview results led to a diagnosis of alcoholism in significant numbers of patients who had no detectable BAC at the time of admission.
In the RAC Shock Trauma Center study, 11 of 24 (46 percent) patients with BAC's of 0 had a history of alcohol dependence at some time in their lives. In the Seattle study (Rivara et al. 1993b), 394 of 1,540 (26 per cent) nonintoxicated patients (BAC = 0 or less than 0.1 percent) had interview results indicative of possible alcoholism. These observations suggest that the search for alcoholics in trauma patients should not be limited to those with elevated BAC's.

SUMMARY
Injury and alcohol are strongly associated. Patients admitted to trauma centers are fre quently intoxicated. Many of those patients require identification and treatment of an underlying drug use problem, most com monly alcoholism. Admission to the trauma center provides clinicians with an opportu nity to accomplish that task, which should lead to significant reduction in illness and death secondary to injury. To date, the primary emphasis of trauma center care for alcoholic patients has focused on the treat ment of physical injuries. The potential to prevent future injury by identifying and treating alcoholism and other drug prob lems, however, has been largely ignored. ■